Early Intervention to Prevent Lymphedema

Lymphedema Progression as charted by BIA and photographs (Courtesy of Impedimed)

THE GOAL OF THIS STUDY INCLUDE:

• Breast cancer treatment commonly includes:
  (a) A mastectomy which is surgery to remove the breast
  (b) The removal of all inbolved lymph nodes near the affected breast
  and under the adjacent arm 
  (c) In addition radiation of frequently performed.
• While these treatments are effective in treating the breast cancer, they also disrupt the functioning of the lymphatic system and often cause lymphedema to develop.
• The goal of this study was to prove that the early detection of developing lymphedema, and the prompt beginning of treatment, could be effective in preventing full-blown lymphedema from developing.

THE HUMAN COST OF LYMPHEDEMA IS HIGH

• Lymphedema is a condition of chronic swelling that cannot be cured.
• Lymphedema causes pain.
• Lymphedema diminishes the patient’s quality of life.
• Lymphedema impairs the range of motion of the affected limb.

This condition is controlled by a daily treatment regimine of:
(1) massage,
(2) wearing compression garments,
(3) careful skin care,
(4) weight control, and
(5) exercise.

• Most commonly, lymphedema associated with breast cancer treatment affects the adjacent arm by causing swelling of the shoulder, arm, joints, and hand.
  It may also affect the area of the trunk surrounding the site breast was removed.
• If a lumpectomy has been performed, the remaining breast tissue frequently becomes swollen, painful, and fibrotic (hardened).
• Lymphedema is due to the inability of lymph to drain normally, and the fluid in this swollen area consists is protein-rich stagnant lymph. 
• Pathogenic bacteria (disease producing) thrive in this fluid and this allows disease producing bacteria to rapidly enter the tissues. Here these bacteria reproduce and thrive thereby  causing the serious infection known as cellulitis.
• This abnormal fluid causes these tissues to deteriorate and to become fibrotic (hardened).

THE NEED FOR PUBLIC EDUCATION

• EARLY DETECTION OF BREAST CANCER SAVES LIVES! Through public education, the lives of many women have been saved by the awareness of the need to detect developing breast cancer at an early stage. These important preventive steps including regular mammograms, plus professional and self-breast examinations.
• NOW IT IS TIME FOR EARLY DETECTION TO PREVENT LYMPHEDEMA! At the time the study was conducted, it was rare for a woman, and often the physician who had not been treated her for breast cancer to know what lymphedema is and the risk it presents. Even when diagnosed with breast cancer, few doctors warn their patients that they are now at risk of developing lymphedema and will remain at risk for the rest of their lives. If they develop lymphedema, the newly diagnosed are not aware that they will have to cope with this condition every day of their lives because lymphedema cannot be cured.
• In the study being described here, the researchers successfully demonstrated that being aware of the risk of developing lymphedema, and taking prompt action, can potentially prevent lymphedema from developing into a lifetime disease.
• Now one of the greatest challenges to oncologists and surgeons is detect the first signs of swelling before serious swellinh begings to develop. The idea time to take initial readings of the fluid in both shoulders is before any surgery or radiation of the breaast is performed. These readings become the baseline for future comparisons.
• Every woman who is diagnosed with breast cancer should know that these preliminary measurements are essential. Public education is also important so that every woman knows if she is diagnosed with breast cancer she must ask her doctor to initiative these preventive steps in a timely manner.

STEP ONE: OBTAINING BASELINES MEASUREMENTS

Imp™ XCA (Courtesy of Impedimed)

• ImpediMed is a bioimpedance device that has been FDA cleared to be used by health care providers to accurately, and quickl,y perform this clinical assessment of an upper limb that is at risk of developing lymphedema.
• Before any treatment begins, the first step in preventing potential problems is obtain a baseline measurements of both arms.
• The easiest and most accurate way to obtain these measurements is through the use of bioimpedance. This non-invasive test measures the composition of body tissues and fluids including lymph. These measurements are used as the baseline for comparison to detect any changes that can be the first signs of developing lymphedema.
• These initial tests, and the results, are taken at a preoperative visit, can be completed within about five minutes, and become part of the patient's chart.

STEP TWO: FOLLOW-UP MEASUREMENTS

• In this study, post-operative measurements were taken at three month intervals.
  These measurements are compared with the baseline figures. Their purpose is to 
  detect changes in the tissues before any visible signs or symptoms of lymphedema
  are visible.
• If any indications of lymphedema such as feelings of heaviness, swelling, or pain are observed by the patient before the three month interval, measurements should be taken immediately and the results are compared with the baseline.
• When a post-operative change in an upper limb indicates a change of >3% a diagnosis of subclinical, or stage 0, lymphedema is made.

TAKE PROMPT ACTION 

• When lymphedema is diagnosed, or suspected, a physician or lymphedema therapist should be consulted immediately and a conservative compression intervention should be started. The following are the steps that were taken during the study.

  A gauntlet for hand compression, (Courtesy of Juzo USA.)

• The patient wore a ready-made knit Jobst garment of 20-30 mm HG compression. (The abbreviation HG stands for mercury. This is a measurement of the amount of pressure the sleeve places on the affected limb.)
• These garments consist of a sleeve and a gauntlet. A gauntlet is a style of compression for the hand that is a partial glove that in which the fingers are completely exposed. A thumb stub holds this garment in place.
• These garments should be fitted by a lymphedema therapist; however for some patients it is possible that an “off-the-shelf” garment will fit. The fit of these garments is important. If necessary, it may be necessary to obtain a custom-made garment.
• These garments are worn during waking hours for a period of four weeks only. They are NOT worn at night because of the risk that the garment could become tangled during sleep and cause a tourniquet-like effect that disrupts circulation.
• At four weeks measurements are taken again.
• If the next measurements indicate that the lymphedema swelling has been reduced to the original (base-line) level, the regimine is changed so that the compression garment and glove are worn only during strenuous activity, air travel, or if symptoms of heaviness develop.
• The patient should continue to return for remeasurement every three months. On the average during the study, volume reduction was maintained at an average follow-up period of 4.8 months. (At this point the study was discontinued.)
• If swelling is not controlled only by garments, the patient should enter a more traditional lymphedema treatment program. The patient should:
• Wear a compression sleeve and glove when traveling by air.
• Avoid having a blood pressure reading taken on the at risk limb.
• Avoid any injection, blood draw, or finger prick in the affected limb. 
  Such treatments can cause a break in the skin that may lead to an infection!
• Avoid any IV placement in the affected limb. The needle breaks the skin and the medication can leak into the tissues and irritate them.
• Avoid having acupuncture needles placed in the affected limb. Although these are very fine needles, they still break the skin.
• Protect the affected area to prevent injuries, sunburn, or insect bites since these can damage the skin.
  When outside wear protective clothing, sunscreen, and insect repellent.
• If even a minor a break in the “at risk” skin occurs, promptly seek medical attention. Antibiotics may be necessary to prevent infections.
• Maintain normal weight. Being even slightly overweight increases your risk of developing secondary lymphedema.
• Exercise. This helps to maintain your general health and the pumping motion of muscles improves the flow of lymph.

ADDITIONAL REFERENCES

• "Preoperative Assesment Enables the Early Diagnosis and Successful Treatment of Lymphema" by N.L. Stout, PT, MPT, CLT-LANA, L.. Pfalzer, PT, MA, PhD, C. McGarvey, PT, DPT, MS, B. Springer, PT, PhD, OCS, SCS, L. H. Gerber, MD, P. Soballe, MD. Cancer June 15, 2008. Vol 112, #12, pages 809-2819.
• "Published Guidelines Further Support Use of Bioimpedance Measurement Technology for Early Assessment of Lymphedema." June 2008.
• “Bioimpedance Analysis in the Assessment of Lymphoedema Diagnosis and Management” by S. Rockson, MD. Journal of Lymphoedema Vol 2, No 1, 2007.
• “The Use of Bioimpedance Analysis to Evaluate Lymphedema” by A. Warren et. al. Annals of Plastic Surgery, Vol 58, No 5, May 2007.
• “Understanding Lymphoedema in the New Millennium” by Professor N. Piller. Journal of Lymphoedema, 2006, Vol 6,
  No 1, pages 60-65.
• "Measuring lymphedema in patients with Breast cancer: go with the flow?" by K.K. Hunt, R. Askew, J.M. Cormier. Breast Cancer Res Treatment January 2009.
• This study was supported by the National Naval Medical Center. 

© LymphNotes.com 2015. This information does not replace the advice of a qualified health care professional.

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Category: Are You at Risk for Lymphedema? Updated: 2015-04-17